24D-001 (24) 257 PROSPECT ST BP-2019-1421
GIs u: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:24D-D01 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv:renovation BUILDING PERMIT
Permit 9 BP-2019-1421
Pro iect0 JS-2019-002299
Est.Cost: $155359.00
Fee:$1092.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contmctor: License:
Use Group: WRIGHT BUILDERS 078114
Lot Size(sa.ft.): 154638.00 Owner. B NAI ISRAEL CONGREGATIONAL
zoning: URB(100y Applicant. WRIGHT BUILDERS
AT. 257 PROSPECT ST
Applicant Address: Phone: Insurance:
48 Bates St (413)586-8287(116) Workers Compensation
NORTHAMPTONMA01060 ISSUED ON.7212019 0:00:00
TO PERFORM THE FOLLOWING WORK:CLASSROOM RENO
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 72/20190:00:00 $1092.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File M BP-2019-1421
APPLICANT/CONTACT PERSON WRIGHT BUILDERS
ADDRESS/PHONE 48 Bates St NORTHAMPTON (413)586-8287(116)
PROPERTY LOCATION 257 PROSPECT ST
MAP24D PARCELD01 001 ZONE URBt100V
THIS SECTION FOR OFFICIAL USE ONLY
PERMIT APPLIC ECKLIST
ENCLCJISED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out k 61
Fee Paid
TypeofConslructiom CLASSROOM RENO
New Construction
Non Structural interior renovations
Addition to Existing.
Accessory Structure
Building Plans Included'
Owner/Statement or License 078114
3 sets of Plans/Plot Plan
THE WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project _ Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER:§
Finding Special Permit Variance'
Received&Recorded at Registry of Deeds Proof Enclosed
_Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
olition Delay
_ 72-Zig
Si tureof Building Official +pate
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission, Department
or public works and other applicable permit granting authorities.
• Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning& Development for more information.
_ r Versionl.7 Commercial Building Permit May 15,2000
Department use only
ity of Northampton Statue of Permit:
JUN 1 4 2019I luilding Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Derr o=BUILDING INSPECTIONS ROOM 100 Water/Well Availability
NORTHAMPTON,run 0+060 M hampton, MA 01060 Two Sets of Structural Plans
phone 413587-1240 Fax 413-587-1272 Plot/Site Plans
APPLICATION TO CONSTRUCT,REPAIR,RENC VATI dE(WOCCI IPANCY OF,OR DEMOLISH ANY BUILDING
OTHER I iAN, ONE OR TWO FAMILY OWEL LING
SECTION 1 -SITE INFORMATION JUN 1 4 2019
1.1 Properly Address: his i action to be completed by office
DEPT OF eUtDIN01N5PECTION9
-� Probp<c+' St. NonTNamPiMtl eA0ras0 Cat 001 Unit
/Jer tl.4nm ptort .Ha Oto 60
(a.`c9ef Gr:y.SPoo,+ RcrrSCy'W Zane Overlay District
1 Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
k W?t'T ';. t-rank X5 .3 li�,�cct St. 1.ic/tAgwA('Mn I tilr. 01C�,U
Name(Print) LvRLV+h AM D•42CNr Current Meiling Adoreea:
v13 .5Yi .(dJJ x lcl
Signature Telephone
2.2 Authorized Agent: if PP I`_ cr, vot-1'.fIM^P-MiJ
Wright %-3':\de+ - Key Hamm r &&A\ o� Wr�syl+_bu�ldefg .cam
Name(Pring / Current Meilings
�
�1
t3 — Sg(� - 8287
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS #106K X 1F7 1000 0 ' -. �
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building - D/ (a)Building Permit Fee
2. Electrical `� p _ (b)Estimated Total Cost of
Construction from 6
3. Plumbing ' ( Building Permit Fee
4. Mechanical(HVAC) O �. 1091.QQ
5. Fire Protection 1
6. Total=(1 121314 Check Number
This Section Fa Official Use Only
Building Pemlit Number Date
Issued
Signature:
Building CommleabcerMepedor of Buildnga Date 7-Z - ZO i9
Versionl.7 Commercial Building Permit May 15,2000 ' ](�{{
SECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 1
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs ❑ Demolition El Repairs El Additions Accessory Building[I
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description Enter a brief description here. CL-A'W-&- A% ¢e .loVA�6 0/.1S
Of Proposed Work:
INGt, MINbF- WOR.-(c- RELocALL�r1r16rR- -kvv INS- h'e'A"DS
SECTION 5-USE GROUP AND CONSTRUCTION TYPE Y �6
USE GROUP(Chedk as aplic❑e) CONSTRUCTION TYPE
❑ ❑A Assembly A-1 A-2 A-3 1A
11
A-4 ❑ A5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ SA ❑
S Storage ❑ 8-1 ❑ S-2 ❑ 5B
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group: 1 b G}},f�ry
dt-
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 8 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
N° qr`
1e 1e
2 ° 2-
3° 34
4m 0
Total Area(so Total Proposed New Construction(so
Total Height(N)
Total Height It
7.Water Supply(M.G.L.0.40.154) 7.1 Flood Zone Information: 7.3 Sawa s isposal System:
Public Private ❑ Zone Outside Flood Zons'Z Municipal On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONINGAa' NtW t&,tk� —M bop
Existing Proposed Required by Zoning
Thi.eluei to he filledy
Building De emn
Lat Size Barr
Frontage
Setbacks Front
Side L: R: L:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
0are minus bldg a p.
mldn
#of Puking aces
F' .
vdime&lacarim
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW 's YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO �0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES ) NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 118 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
1'fano iJ.01c-" Not
Applicable ❑
Name(Registrant):
10 —n nhaan ST. [Sp Mao 1 M0. 0?)t9 Registration Number p
Address �I D. 0'('( 1
Expiretion Date
�} -�+4z 0800.
Signature elepMne
9.2 Reglstened Professional Englneer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Espiralion Date
Name Area of Responsibility
Address Registration Number
Signature Telepl E.iretlen Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Fxpirabon Dale
9.3 Cwnsol Contractor
� Yi q)\f Qom;�.di SnC Not ApplicabbO
Comte any airy me:
K e.t1+ H wttl�
Responsible In Charge of Construction
LIQ 6atcs S+. Wpo
Adtlress -
413-59c-biv�
Signa Telephone
Versionl.7 Commercial Building Permtt May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE
9.1 Regleteavell Arehibok
Not Applicable ❑
Name(RegktroK):
iSTen l la G'aliy Registration Numbs
dr 1=arv,t,wn ST
x.31 I 61��
Atlbasa
,�I} y Erplration Dab
Signature Telephone
9.2 Registered Protssstonal Enginser(s):
Name Area of Reeponslbllity
I
gddreee _— -- Registration Number
Signature Telephone Expi Date
I i
Name Area of Responslbllity
I
Address Reglatretion Number
I I
Signature Telephone Expiration Dale
iName Area of Responsibility
Address Registration Number
i
Signature Telephone Expiretion Date
i I
Name --�_-- Area of Responsatllity
i
Atltlreea Registration Number '
Signature Telephone Expiration Dale
9.3 General Contractor
6J Yt 4a1' 'lde✓e. —nc Not Applicable ❑
Company e:
Keiil He l _
Responsible In Charge of Constmctl
11B 60Scs St, vihhw«pto Mc 0 \O(aP
aetlrese
413 ssc-8za
Slgnalur Telephone
Venionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, \_kkG .M1
1 . t—f i.n{[ t (Fxr--t;v as Owner of the subject property
hereby authorize Qv'.Ue.ri _ to
act on my� ative to work authorized by this building permit application.
6- f3 - Zo�9
Signature or Dwer
I, Date
Moog-
Y k 1 ^ �w`ELI " tUtC"f`"
,as Owner/Authorized
Agent hereby declare that the statements and Information on the foregoing application are true and accurate,to the best of my knowledge
,gnt' ief.
Signed u of the pains and penalties of perjury.
Print Nam
Signature of Inner/Agent Data
SECTION 12.CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: NotApplicable [3I\
Nam.of License Holden 2'� NaN1C\ 0 -+% �i L{
License Number
48 Zr ), Rd F�^cm 4pv Mp 010a� 0�� � 3� 24 d0
Address Expiration Date
Signalu Telephone
SECTION 13-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 56 No
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 7 � ep- o S i° 'r S-r-
The debris will be transported by:
VELD t M A'
The debris will be received by:
Building permit number:
Name of Permit Applicant I ' i 1' IN P4 V4+T- �A`�Q
6- 13- =L
Date Signature of Permit Applicant
Initial Construction Control Document
To be submitted with the building permit application by a
Registered Design Professional
for work per the ninth edition of the
Massachusetts State Building Code, 780 CMR, Section 107
Project Title: Classroom Renovations Date: June 6. 2019
Property Address: Lander Grinspoon Academy 257 Prospect Street, Northampton, MA,01060
Project: Check(x) one or both as applicable: New construction (x)Existing Construction
Project description: This m' t my'des an Art RQQ,h and Makempaceon the round fl r level of Lander
[' n focuses on incmasing the m within th
�hml by remrkina the enhy maidpr.easin Me an le of a roach in Plan and epladna a solid wall with full hei ht glazing.It also blurs
shared'T of "stoma a room with movable dividers to allow stomae ovefflow and Dafficipation beMe.n the classes
Inva na Me des of cmft and assembly as alit eral part of the school sheathin yed W revflic elements
buildin 's inner mn.Wctbn.Exposed truss..and a stn etl bearing w II at the ent are key in rfledi,,u the s int of makina.whil.als.in asin
the height and openness of the space.
In tandem with the raw elements of the building h t s tem and woftepch sew na the An Rwm and
Makers ace spedwely The colo and m t d 1 palettes of them surfaces am light and neutral all�ina the
u of the students to be showcased.
The central"Toolbox"is exc standard 4X8' pod anels II lined with
acoustic insulation.Each Panel is Dain etl a milled to inscribe a continuous graphic of icons nsand by Hebrew
Sall amuhv The'nscnbed grooves also work to deflect and dampen sound between the two roams.
The Tenovation of these spams will a,ye then f LGA aess to modern diq ilal teghnalogy whiler n thenin the Imnd to
t ditional cmftevoIvha alonasiden of new tools.
I J. Frano Violich MA Registration Number: 7034 Expiration date: 8/31/2019 am a registered design
professional, and I have prepared or directly supervised the preparation of all design plans,computations and
specifications concerning:
(x)Architectural Structural Mechanical
Fire Protection Electrical Other.
for the above named project and that to the best of my knowledge, information, and belief such plans,
computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780
CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my
designee)shall perform the necessary professional services and be present on the construction site on a regular
and periodic basis to:
1. Review, for conformance to this code and the design concept, shop drawings, samples and other
submittals by the contractor in accordance with the requirements of the construction documents.
2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable.
3. Be present at inter vats appropriate to the stage of construction to become generally familiar with the
progress and qualit y of the work and to determine if the work is being performed in a manner consistent
with the approved construction documents and this code.
r
Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107.
When required by the building official,l shall submit field/progress reports(see item 3.)together with pertinent
comments, in a form acceptable to the building official.
Upon completion of the work,I shall submit to the building official a'Final Construction Control Document'.
Enter in the space to the right a "wet" or electronic
signature and seal:
i miq
vo0110a
No.07094 1
a0810M p
w
Phone number: 617.442.0800 Email: fviolich®kvarch.net
Building Official Use Only
Building Official Name: permit No.: Date:
Note 1.Indicate with an')C project design plans,computations and specifications that you prepared or directly supervised.If'other'is
chosen,provide a description.
Version 01 01 2018
\ The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Sheet,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
ulkikers'Compensation Insurance Allidavib Budders/Contractors/Electriciaua/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Bunness/OrganizatioMaMividuap: WYTu'l4fa S.nr
Address: W 8al'e5 $e
City/State/Zip: orµ bAAo, 010&0 Phone M 1113 -678C- AA9-+
Ar.yau m employer?Check the.ppropriate boa: Type of project(required):
LE]I..employer with employees(fidl mllor parr-rime).• 7. ❑ wconstmctron
2.❑Iamamle propdaor or laamership andhavem employers woddng forme nt $, Rempdohng
any capacity.[No workers'comp.insurance rationed]
3.❑I mta homrownor&to all workm elf. oworkas' �. 1 9. El Demolition
g ys pa camp.maamnee talw 1
4.❑I w a homawner and wi0 be hiring cmtracmrs to conduct all work m my property. I will IU❑Building addition
erume that all contractors either have coatker%compeastakn imwance or are sole ll.❑Electrical repays or additions
aura with no employees. 12.❑Plumbing repairs or additions
5. Ieme sub ro cwrmctm andIrave Erredthesub<antrseco listedontheanmhed sheet. 13.�Roofrepairs
These sub<wtracmrs have employees and hen worker'comp.ivurenu.t
6.❑We are a cotporadan and its alfioers have rommisedtheir right ofe man tion per MGL c. 14.❑Other
152,41(4),and we hove no employees.[No workers'com,r ineurance rttluued.]
•Any applicmr that crecka box#1 mart am fill out the nation below abm im,their workers'compmastio r policy information.
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside cmtmctors.submit a new affidavit indicating such.
tContractors that chak this box must attached an additional sheet showing the name of the sub-wnnactora and state wheNer or at those en ams have
employees. If me sub-contractors have employees,they most provide their workers comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Q T . /t
Policy#or Self-ins.Lic.M /,A CC 2mawb 534AOI vt Expiration Date: (5 3j 61�_
Job Site Address: da'?6c coer_F St'. City/State/Zip:�s ye{6n1" 1--cs
Attach a copy of the workera'compensation policy declaration page(showing the policy number an "piratlon date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify u do TepVandpenaides ofperjury that the information provided above is true and correct.
Signature: Date' 0
Pbone#� 1.113-G16 -S d$-+ _
Oficial use only. Do not write in this area,to be completed by city or fawn ojf4ciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Paramour to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than tivice apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work and acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)mame(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or parmers,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be retained to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/liceme number which will be used as a reference number. In addition,an applicant
that must submit multiple pemuUlicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 w .mags.gov/dia
ACO° CERTIFICATE OF LIABILITY INSURANCE DA EMMmpYYYYI
0&112019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and Conditions of the Policy,certain policies may require an endorsement A statement on
this certificate does not Confer rights to the Certificate holder in lieu of such endamement(s).
FROOUCER w.NTAuy Jenne Duval,CISR Elite
Webber&Grinnell PHONE (413)5800111 R (413)588NM8I
NC "o'
8 Nath King Street PODREss: Xurel®webberendgrinnall.com
INSUREIXSIA MMMGCOVERAGE Mies
Nodhamplon MA 01060 MaeRERA: Amelia Pred.obon 41380
FREDINSUREAeWIIgM Builders,Inc. INSURER ceve....'
48 Bates SBeet INSURER E
:
NOMamplon MA 01080 INSURER F:
COVERAGES CERTIFICATE NUMBER: Masler2020 REVISION NUMBER:
THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANOINGANY REQUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,
E%CLUSIONSAND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS
LTR MEOFNW.CE am ViVOI POLICY NUMBER MYRI MNRS
COMNERCIALGEHEMLLWBILITT EACH OCCURRENCE S 1,000,090
CUIMSMADE ®OCCUR PREMISES En-oneM a iPo'QPo
MEDS Vvycm Rvaau f SON
A 8500088268 QSA"C019 OS101202p pERsaiALl AJrvIMuflY f 1.0OOp00
GENLAGGREGATELMRAPPUIDURER: GENERPLAGGREGATE f 2.000.000
POLICYP"�
JECL LOC '. P0.ODUCT3-CgAPpPAGO f 2•01)(1•000
OTHER: Employee Senate f 2,000,000
Al1TOMOGRE U&SRTY .M QEOISINGIE LIMB f 1,000,000
ANYSUTO ..DRYINJURYIPer Mrs.) a
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CERTIFICATE HOLDER CANCELLATION
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AUTHORIZED REPRESENTATIVE
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